You must take care to abide by local confidentiality, data security and information governance protocols when adding details into this form. In particular, you must remove all personal and patient identifiable data. If you are unable to do this for specific items of information, you should log the existence of the information in this form but provide the information itself separately to your appraiser.

Remember, you are providing this information primarily to your appraiser. After your appraisal is signed off, your responsible officer or other person with appropriately delegated authority will receive a copy of the form, specifically to read the appraisal outputs (the appraiser’s statements, the appraisal summary, and your personal development plan).

Your responsible officer may also access the rest of this form and all of your supporting information (whether attached to this form or provided separately) when considering your fitness to practise (for your revalidation recommendation or in other circumstances) and for quality assurance purposes. Your responsible officer can provide you with more information about who may view your form and the circumstances under which they may do so.

Throughout the appraisal process, doctors and appraisers must adhere to local information governance protocols, particularly in relation to the sending of this form and any supporting information by appropriate email or other means and in relation to the storing/ filing of this form and any supporting information in an appropriate place and for an appropriate length of time.

"I confirm that I have completed this form and reflected on the supporting information to support this appraisal. I am responsible for the contents and confirm that it is appropriate for this information to be shared with my appraiser and responsible officer."